Paul H. McCormick

Introduction: Neoadjuvant systemic and immunotherapy strategies in non-metastatic colon cancer have demonstrated high pathological response rates, raising interest in surgery-sparing approaches. Circulating tumour DNA (ctDNA) is an emerging biomarker for treatment response and minimal residual disease, but its role in guiding surgical omission in colon cancer remains unclear. This systematic review evaluates the diagnostic and prognostic accuracy of ctDNA in predicting pathological response following neoadjuvant therapy in non-metastatic colon cancer. Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Embase/MEDLINE, Scopus, and the Cochrane Register were searched from inception to 21 October 2025. Eligible studies included adults with non-metastatic colon cancer treated with neoadjuvant therapy who had serial ctDNA assessment prior to surgery. Results: Three cohort studies comprising 100 patients met inclusion criteria. Baseline ctDNA detection ranged from 42% to 84%. Across studies, ctDNA clearance following neoadjuvant therapy was consistently associated with major pathological response or pathological complete response, whereas persistent ctDNA strongly predicted residual viable tumour at resection. In the largest prospective cohort, 5 of 26 patients (19%) achieved ctDNA clearance prior to surgery; all were pathological responders, while 19 of 26 patients (73%) with persistent ctDNA demonstrated no pathological response. No study reported pathological complete response in the presence of persistently positive ctDNA. No prospective trial formally evaluated ctDNA-guided surgical omission. Conclusions: Current evidence does not support the use of ctDNA alone to guide omission of surgery after neoadjuvant therapy in non-metastatic colon cancer—even in patients who show complete pathological response. While persistent ctDNA reliably identifies patients with residual disease, ctDNA clearance lacks sufficient positive predictive value to safely forego surgery. Prospective trials with standardised ctDNA platforms and predefined non-operative management protocols are required before ctDNA-guided organ preservation can be recommended.

Background: Colorectal cancer (CRC) mainly affects older adults, yet elderly patients are underrepresented in outcomes research. Accurate risk stratification tools, such as the Charlson Comorbidity Index (CCI), are essential for guiding surgical decisions in this group. Methods: We conducted a retrospective review of patients aged 75 years or older who underwent colorectal cancer resection at a tertiary centre between January 2019 and September 2024. Clinical, pathological, and molecular data were analyzed. The primary outcome was a composite of major postoperative complications (Clavien–Dindo grade 3 or higher) or 30-day mortality, stratified by CCI (5 or higher vs. less than 5). Statistical tests included chi-square, Fisher’s exact, and Mann–Whitney U as appropriate. Results: The median age was 81 years (range 75–97), with 59.7% male. CCI ≥ 5 was observed in 24.6% (51/211). The primary composite outcome of major postoperative complications or 30-day mortality occurred in 15/51 (29.4%) patients with a CCI ≥ 5 compared to 19/160 (11.9%) with a CCI < 5 (p = 0.04). Major complications occurred in 18.5% (39/211) of cases, and the 30-day mortality rate was 3.3% (7/211). Laparoscopic resection was independently protective in multivariate analysis (adjusted OR 0.37, p = 0.048), while age ≥85 and emergency presentation were not statistically significant predictors. Conclusions: Colorectal resection in patients aged ≥75 is linked with acceptable morbidity and low short-term death rates. A CCI ≥ 5 significantly predicts adverse outcomes and should be included in preoperative assessments. Minimally invasive surgery seems advantageous and should be considered, when possible, to enhance results in this high-risk group.

Background: We aim to ascertain prognostic factors in the current management of anal cancer within this study. Methods: We reviewed the management and outcomes of anal cancer cases over a seven-year period, inclusive (2016–2023). The primary objectives were to assess the demographic characteristics, clinical presentation, and outcomes of all anal cancer patients within our institution. Kaplan–Meier survival analysis was used to estimate survival differences between cohorts, with statistical significance determined using log-rank testing. Cox proportional hazards regression was utilised to identify prognostic factors. Cox regression hazard ratios were reported along with confidence intervals and p-values. Results: The median follow-up time for the study was 29.8 months. Seventy-five patients with anal cancer were included in this study, with 88% (66/75) being squamous cell carcinoma (SCC) and the majority having regional disease (82.7% (62/75)). The median age at diagnosis was 63.4 years (36–94). There was a female preponderance (57.3% (43/75)). In total, 84% (63/75) underwent definitive chemoradiation (dCRT), with 7/63 (11.1%) requiring a salvage abdomino-perineal resection (APR) for residual or recurrent disease. Adverse prognostic indicators include those with T4 disease hazard ratio = 3.81, (95% CI 1.13–12.83, * p = 0.04), poorly differentiated tumour disease HR = 3.37, (95% CI 1.13–10.02, * p = 0.04), having N2 nodal status HR = 5.03, (95% CI 1.11–22.8, * p = 0.04), and having metastatic disease at diagnosis HR = 5.8, (95% CI 1.28–26.42, * p = 0.02). Conclusion: Presenting characteristics including stage, nodal, and differentiation status remain key prognostic indicators in those diagnosed with anal malignancy.

Introduction: Goblet cell carcinoid (GCC) is a rare and poorly understood appendiceal neoplasm, exhibiting mixed histological and aggressive clinical features. Current guidelines recommend right hemicolectomy in all cases, although there is conflicting evidence that appendicectomy alone may be sufficient. This review aims to identify the optimal surgical management for appendiceal GCC. Methods: A systematic review was performed by searching MEDLINE, Embase, Scopus and the Cochrane Register of Controlled Trials. Randomised controlled trials, cohort studies or large case series (>5 patients) reporting clinical outcomes for patients undergoing surgical management of GCC of the appendix were included. Outcomes extracted included participant and tumour characteristics, type of surgery and survival data. Results: A total of 1341 studies were retrieved. After duplicate removal, 796 titles were screened for relevance prior to abstract and full text review. A total of six studies were included for analysis, comprising 3177 patients—1629 females and 1548 males. The median age ranged from 51 to 72 years. A total of 2329 patients underwent right hemicolectomy, while 824 were treated with appendicectomy only. Overall, the included studies report increased survival in patients undergoing right hemicolectomy compared to appendicectomy alone. A meta-analysis was not possible due to insufficient data reported in the published literature to date. Conclusions: There is no consensus regarding the optimal surgical management of appendiceal GCC, as outcomes-based data comparing surgical interventions are lacking. It is possible that some patients with favourable features are overtreated. The absence of robust evidence to support a more conservative approach means that right hemicolectomy remains the standard of care for all patients, in keeping with current international guidelines. The rarity of this condition and limited data in the published studies remain barriers to evidence-based best clinical practice.

Radiogenomics, a sub-domain of radiomics, refers to the prediction of underlying tumour biology using non-invasive imaging markers. This novel technology intends to reduce the high costs, workload and invasiveness associated with traditional genetic testing via the development of ‘imaging biomarkers’ that have the potential to serve as an alternative ‘liquid-biopsy’ in the determination of tumour biological characteristics. Radiogenomics also harnesses the potential to unlock aspects of tumour biology which are not possible to assess by conventional biopsy-based methods, such as full tumour burden, intra-/inter-lesion heterogeneity and the possibility of providing the information of tumour biology longitudinally. Several studies have shown the feasibility of developing a radiogenomic-based signature to predict treatment outcomes and tumour characteristics; however, many lack prospective, external validation. We performed a systematic review of the current literature surrounding the use of radiogenomics in rectal cancer to predict underlying tumour biology.

Introduction: Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. ‘Selective’ patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates. Methods: A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes. Results: Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/− 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/− 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5–17.5 months) and 25.9 months (IQR 6.2–39.7 months), respectively. Conclusions: Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.

Background: Synchronous para‐aortic lymph node metastasis (PALNM) in colorectal cancer (CRC) is a relatively rare clinical entity. There is a lack of consensus on management of these patients, and the role of para‐aortic lymph node dissection (PALND) remains controversial. This systematic review aims to describe the survival outcomes in colorectal cancer with synchronous PALNM when lymph node dissection is performed.Methods: A systematic review of Pubmed, Embase and Web of Science databases for PALND in CRC was performed. Studies including patients with synchronous PALNM undergoing resection with curative intent, published from the year 2000 onwards, were included.Results: Twelve retrospective studies were included. Four studies reported survival outcomes for rectal cancer, two for colon cancer and six as colorectal. Survival outcomes for 356 patients were included. Average 5‐year overall survival (OS) was 22.4%, 33.9% and 37.7% in the rectal, colon and colorectal groups respectively. Three year OS in the groups was 53.6%, 46.2% and 65.7%.Conclusion: There remains a lack of quality data to confidently make recommendations regarding the management of synchronous PALNM in colon and rectal cancer cohorts. Retrospective data suggests a benefit in highly selective cohorts and therefore a case‐by‐case evaluation remains the standard of care.

Background: Acute sigmoid volvulus (ASV) represents a small but significant portion of cases of large bowel obstruction, especially in the elderly and co-morbid. Given the characteristics of the patient cohort most commonly affected, a non-operative/conservative approach is often undertaken but is associated with a high rate of recurrence. Objective: We sought to evaluate outcomes for those patients who underwent non-operative management, emergency surgery or staged, semi-elective surgery following decompression for ASV at our institution. Methods: Hospital in-patient enquiry (HIPE) data were used to identify all patients who presented with sigmoid volvulus between January 2005 and June 2020 inclusive. Patient notes were interrogated, including surgical and endoscopic procedures performed. Patient demographics and co-morbidities were recorded. Results: Thirty-nine patients were treated over a 15-year period with a mean age of 73 years at first presentation (range 36–93). Twenty-two patients (56%) had just a single admission for ASV with three deaths in this group. Seventeen patients (44%) had more than one admission with volvulus due to recurrence after a decompression-only strategy on the index admission. Of these, three succumbed to complications of their subsequent episodes of volvulus. Twenty-five patients underwent surgical intervention (fifteen on, or shortly following, their first admission and ten following at least two admissions for ASV). The overall mortality in the operative group was 2/25 (8%) with both deaths in those undergoing emergency surgeries. Five patients were treated successfully with endoscopic measures alone and had required no further interventions at the time of compiling data. Conclusion: There is a high recurrence rate following non-operative management of acute sigmoid volvulus and consequently, a cumulative increase in the attendant significant morbidity and mortality with subsequent episodes. Given the relatively low complication rate of definitive surgery, even in those patients perceived to be high risk, we contend that all patients should be considered for early surgery to prevent the likely recurrence of sigmoid volvulus.